Massage for neck pain.

BACKGROUND: Massage is widely used for neck pain, but its effectiveness remains unclear. OBJECTIVES: To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache. SEARCH METHODS: We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive. MAIN RESULTS: We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events). AUTHORS' CONCLUSIONS: The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.

The effect of ultrasound or phonophoresis as an adjuvant treatment for non-specific neck pain: systematic review of randomised controlled trials.

OBJECTIVE: To determine the effectiveness of ultrasound/phonophoresis as an adjuvant to exercise or manual therapy for the improvement of patient-centred outcomes in adults with non-specific neck pain (NSNP). METHODS: Seven electronic databases were systematically searched up to September 2020. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used to judge the Quality of Evidence (QoE). RESULTS: Six studies involving 249 participants were included. The QoE was very low GRADE. Phonophoresis with capsaicin plus exercise improved pain at immediate post-treatment (MD: -3.30 [-4.05, -2.55]) but not with diclofenac sodium plus exercise as compared to exercise. Continuous ultrasound (CUS) plus exercise improved pain and pressure pain threshold (PPT) at immediate post-treatment (pain: MD: -3.42 [-4.08, -2.7]); (PPT: MD: 0.91 [0.68, 1.14]) and at intermediate-term as compared to exercise. CUS or high power pain threshold (HPPT) ultrasound plus manual therapy and exercise showed no benefit for pain reduction (MD: -0.75 [-2.08, 0.58]) did not improve function/disability (MD: -1.05 [-4.27, 2.17]) at immediate or short-term as compared to manual therapy and exercise. CONCLUSIONS: Due to high risk of bias, inconsistency, and indirectness the QoE is very low in support of benefit of ultrasound/phonophoresis as an adjuvant treatment for NSNP.Implication for rehabilitationDue to high risk of bias, inconsistency, and indirectness the quality of evidence (QoE) is very low in support of benefit of adding ultrasound or phonophoresis to exercise or manual therapy for pain reduction or improvement in function/disability for those with sub-acute and chronic myofascial associated neck pain. However, our confidence in the findings is very low and conclusions are likely to change as more evidences emerges.Clinicians using ultrasound therapy as an adjuvant intervention for management of chronic myofascial associated neck pain should carefully consider the available evidence on ultrasound, including the benefits and costs involved.

Key attributes of integrated community-based youth service hubs for mental health: a scoping review.

BACKGROUND: Community-based, integrated youth service hubs have the potential to address some of the longstanding issues with mental health services for youth, including problems with access and system fragmentation. Better understanding of these approaches, particularly efforts to create a single point of entry to comprehensive, evidence-based services through youth service hubs, is needed to help guide future implementation and evaluation. This scoping review identifies the key principles and characteristics of these models of care, as well as the state of the literature, particularly with regard to implementation and replicability. METHOD: Electronic databases and grey literature sources were searched for material from 2001 to 2019, with diverse search terms capturing the concept of "integrated" or "one-stop shop" youth mental health services. Title/abstract and full text review were conducted, as well as additional focused searching. After screening 4891 texts at the title/abstract level and 496 at the full-text level, 110 documents were included for data extraction. RESULTS: Several integrated care hub models for youth mental health services and related frameworks were identified internationally, largely in high-income countries. Common principles included an emphasis on rapid access to care and early intervention, youth and family engagement, youth-friendly settings and services, evidence-informed approaches, and partnerships and collaboration. Program characteristics also revealed similarities (e.g., providing evidence-informed or evidence-based services in youth-friendly spaces), with some differences (e.g., care coordination methods, types of service providers), potentially attributable to lack of available information about key ingredients. Outcome research was limited, with few rigorous evaluations of youth outcomes. Moreover, sufficient information for replication, community evaluation of feasibility or actual implementation was rarely provided. CONCLUSION: Internationally, integrated youth service hubs were found to share common key principles, while providing comprehensive services to youth with mental health difficulties. There is a great need for common language and measurement framework to facilitate replication, rigorous evaluation of outcomes, knowledge exchange, and dissemination of findings.

Towards high-quality, useful practice guidelines for child and youth mental health disorders: protocol for a systematic review and consensus exercise.

INTRODUCTION: The quality of clinical practice guidelines (PGs) has not been evaluated in child and youth mental health (CYMH). To address this gap, we will: (1) conduct a systematic review (SR) to answer the question 'among eligible PGs relevant to the prevention or treatment of CYMH conditions, which PGs meet criteria for minimum and high quality?'; (2) apply nominal group methods to create recommendations for how CYMH PG quality, completeness and usefulness can be strengthened. METHODS AND ANALYSIS: SR: Potentially eligible PGs will be identified in 12 databases using a reproducible search strategy developed by a research librarian. Trained raters will: (1) apply prespecified criteria to identify eligible PGs relevant to depression, anxiety, suicidality, bipolar disorder, behaviour disorder (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder) and substance use disorder; (2) extract descriptive data and (3) assess PG quality using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Scores on three AGREE II domains (rigour of development, stakeholder involvement, editorial independence) will designate PGs as minimum (≥50%) or high quality (≥70%). Nominal group: Four CYMH PG knowledge user groups (clinicians, mental health service planners, youth and adult family members) will participate in structured exercises derived using nominal group methods to generate recommendations to improve PG quality, completeness and usefulness. ETHICS AND DISSEMINATION: Ethics approval is not required. Study products will be disseminated as follows. A cross-platform website will house eligible CYMH PGs and their quality ratings. Twitter and Facebook tools will promote it to a wide variety of PG users. Data from Google Analytics, Twitonomy and Altmetrics will inform usage evaluation. Complementary educational workshops will be conducted for CYMH professionals. Print materials and journal articles will be produced. PROSPERO REGISTRATION NUMBER: CRD42017060738.

Youth friendliness in mental health and addiction services: protocol for a scoping review.

INTRODUCTION: To better reach youth in need of mental health and addiction (MHA) services, there is increasing emphasis on making MHA services 'youth friendly.' However, it is unclear what youth friendliness means on a practical level. This scoping review explores (1) how youth friendliness in mental health services is defined in the literature, (2) what characteristics make MHA services youth friendly and (3) how youth friendliness is expected to impact service use by young people. METHODS: A search will be conducted of eight electronic bibliographic databases over the last 15 years (2002-2017) to identify literature on youth friendliness consistent with the modern youth experience. Grey literature will also be searched. The search and literature selection process will include all study designs, as well as non-research literature. Two independent raters will determine eligibility based on a review of the titles and abstracts of the identified literature, followed by full text reviews when required. Data will be extracted from the identified literature and then synthesised using qualitative and quantitative approaches. As a final step, we will conduct stakeholder consultations with youth, family members and service provider groups to validate the findings and identify any characteristics of youth friendliness that they deem important that were not reported in the findings. ETHICS AND DISSEMINATION: Results will be disseminated through a peer-reviewed publication, as well as international, national and local conference presentations. Agency reports will be developed to present the findings in a user-friendly format, including a youth-friendliness checklist for youth-serving organisations. Research ethics approval has been obtained for the consultation component of this study.

Testing the effectiveness of simplified search strategies for updating systematic reviews.

OBJECTIVE: The objective of the study was to test the overall effectiveness of a simplified search strategy (SSS) for updating systematic reviews. STUDY DESIGN AND METHODS: We identified nine systematic reviews undertaken by our research group for which both comprehensive and SSS updates were performed. Three relevant performance measures were estimated, that is, sensitivity, precision, and number needed to read (NNR). RESULTS: The update reference searches for all nine included systematic reviews identified a total of 55,099 citations that were screened resulting in final inclusion of 163 randomized controlled trials. As compared with reference search, the SSS resulted in 8,239 hits and had a median sensitivity of 83.3%, while precision and NNR were 4.5 times better. During analysis, we found that the SSS performed better for clinically focused topics, with a median sensitivity of 100% and precision and NNR 6 times better than for the reference searches. For broader topics, the sensitivity of the SSS was 80% while precision and NNR were 5.4 times better compared with reference search. CONCLUSION: SSS performed well for clinically focused topics and, with a median sensitivity of 100%, could be a viable alternative to a conventional comprehensive search strategy for updating this type of systematic reviews particularly considering the budget constraints and the volume of new literature being published. For broader topics, 80% sensitivity is likely to be considered too low for a systematic review update in most cases, although it might be acceptable if updating a scoping or rapid review.

Essential components of integrated care for youth with mental health and addiction needs: protocol for a scoping review.

INTRODUCTION: Efforts to move towards integrated care have been met with increased interest and enthusiasm in recent years given the potential to improve care and population health while containing costs. However, there is a need to better understand community-based integrated care approaches for youth with mental health and/or addiction concerns to guide future implementation efforts and develop a set of standards for key components. The objectives of this scoping review are to: (1) identify the populations, settings, service providers, interventions, infrastructure and care coordination methods that have been included in integrated care for youth with mental health and/or addiction needs and (2) identify constructs that have been measured and evaluated (eg, outcomes, engagement) in the context of youth integrated care. METHODS AND ANALYSIS: Seven electronic databases and several grey literature sources will be searched for material from 2001 to 2016. Inclusion criteria will be broad with respect to type of work, as we will include all types of research studies as well as non-research studies that provide information relevant to characteristics and constructs measured in the context of integrated care for youth mental health. Titles and abstracts will be independently screened for eligibility by two raters using inclusion criteria. Full-text articles will then be accessed and independently screened for inclusion. A formal data extraction method will be employed, enabling synthesis of results in quantitative and qualitative formats. ETHICS AND DISSEMINATION: Results will be widely disseminated to various stakeholders to inform implementation and research efforts. Findings will also launch a Delphi method study leading to the development of an assessment tool for youth mental health services integration. This review does not require ethics approval.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews.

OBJECTIVE: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts. METHODS: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings. RESULTS: No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%. CONCLUSIONS: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Cognitive behavioral therapy age effects in child and adolescent anxiety: an individual patient data metaanalysis.

BACKGROUND: Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap. QUESTION: Does age moderate CBT effect size, measured by a clinically and statistically significant interaction between age and CBT exposure? METHODS: All English language RCTs of CBT for anxiety in 6-19 year olds were identified using systematic review methods. Investigators of eligible trials were invited to submit their individual patient data. The anxiety disorder interview schedule (ADIS) primary diagnosis severity score was the primary outcome. Age effects were investigated using multilevel modeling to account for study level data clustering and random effects. RESULTS: Data from 17 of 23 eligible trials were obtained (74%); 16 studies and 1,171 (78%) cases were available for the analysis. No interaction between age and CBT exposure was found in a model containing age, sex, ADIS baseline severity score, and comorbid depression diagnosis (power ≥ 80%). Sensitivity analyses, including modeling age as both a categorical and continuous variable, revealed this result was robust. CONCLUSIONS: Adolescents who receive CBT in efficacy research studies show benefits comparable to younger children. However, CBT protocol modifications routinely carried out by expert trial therapists may explain these findings. Adolescent CBT protocols are needed to facilitate the transportability of efficacy research effects to usual care settings where therapists may have less opportunity for CBT training and expertise development.

Prevention of substance use in children/adolescents with mental disorders: a systematic review.

OBJECTIVE: WE CONDUCTED A SYSTEMATIC REVIEW TO ANSWER THE QUESTION: Among youth ≤18 years of age with a mental disorder, does substance use prevention compared to no prevention result in reduced rates of substance use/abuse/disorder (SUD)? The review was requested by the Ontario Ministry of Health and Long-term Care through the Canadian Institutes for Health Research Evidence on Tap program. METHODS: A four-step search process was used: Search 1 and 2: Randomized controlled trials (RCTs) that evaluated a SUD prevention intervention in individuals with a mental disorder who were: 1) ≤18 years; or, 2) any age. Search 3: Observational studies of an intervention to prevent SUD in those with mental disorder. Search 4: RCTs that evaluated a SUD primary prevention skills-based intervention in high-risk youth ≤18 years. RESULTS: Searches 1 and 2: one RCT conducted in youth was found; Search 3: two observational studies were found. All three studies reported statistically significant reductions in substance use. Search 4: five RCTs were found with mixed results. Methodological weaknesses including inadequate study power may explain the results. CONCLUSIONS: Little is known about effective interventions to prevent SUD in youth with a mental disorder. Effective SUD primary prevention programs exist and should be evaluated in this high-risk group.